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Additional License-Permit Application ABC-239 - California

Additional License-Permit Application Form. This is a California form and can be used in Department Of Alcoholic Beverage Control Statewide .
 Fillable pdf Last Modified 6/25/2012
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Department of Alcoholic Beverage Control State of California ADDITIONAL LICENSE/PERMIT APPLICATION (ABC Use Only) Effective July 1, 2012, Assembly Bill No. 1424, authorizes the State Board of Equalization and the Franchise Tax Board to share taxpayer information with the Department of Alcoholic Beverage Control. The Department may suspend, revoke, and refuse to issue a license if the licensee's name appears in the 500 largest tax delinquencies list. (Assembly Bill No. 1424, Chapter 455) LICENSE NUMBER RECEIPT NUMBER FEE PAID $ DISTRICT CODE GEO CODE SECTION 1 - LICENSEE(S) INFORMATION 1. LICENSEE'S NAME 4. PROPOSED PREMISES ADDRESS 2. DOING BUSINESS AS (DBA) 3. DATE 5. DISTRICT OFFICE 6. MAILING ADDRESS 7. LICENSEE'S PHONE NUMBER SECTION 2 - APPLICATION FOR PERMIT/LICENSE 8. TYPE OF PERMIT/LICENSE 9. NUMBER OF PERMITS/LICENSES 10. PRINCIPAL/MASTER LICENSE NUMBER I/We apply for the permit/license(s) checked below. a. Caterer's Permit (Type 58) b. Controlled Access Cabinet (Type 66) c. Portable Bar (Type 68) d. Beer & Wine Importer (Type 09) e. Brandy Importer (Type 11) f. Distilled Spirits Importer (Type 12) g. Duplicate (Type 02) h. Duplicate (Type 47) i. Duplicate (Type 48) j. Event Permit (Type 77) k. Certified Farmer's Market (Type 79) l. Other SECTION 3 - SIGNATURE (Only one signature required. Extra line provided for your convenience if your entity requires two signatures.) 11. CERTIFICATION FOR SIGNATURE OF A LICENSED PRINCIPAL I declare under penalty of perjury that I am authorized to sign for the licensed entity identified in Item 1, above. I have read the foregoing and know the contents thereof. Signature must be notarized unless witnessed by ABC employee. 12. SIGNATURE 13. PRINTED NAME AND TITLE 14. DATE SIGNED ABC USE ONLY RECOMMENDATION AGENT'S SIGNATURE (If investigation required) DATE SIGNED RECOMMENDATION SUPERVISOR'S SIGNATURE DATE SIGNED Distribution: Original to Headquarters Cashier ABC-220 to follow Conditions to follow; Hold in HQ until received Copy to District file Copy to Licensee ABC-239 (rev. 06/12) American LegalNet, Inc.
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